Appropriate use criteria for revascularization

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and Keywords: AUC

Overview

The goal of the appropriate use criteria is to provide general guidance to both patients and clinicians about the appropriateness of revascularization procedures. The committee acknowledges that these guidelines are not meant to be a substitute for clinical judgment. Even if the appropriateness of a revascularization is listed as "uncertain" this does not mean that a physician should not perform a PCI. Likewise, even if revascularization is deemed to be "appropriate" by the appropriate use criteria, there may be mitigating circumstances that indicate PCI should not be undertaken. Rather than individual scenarios, the appropriate use criteria are meant to evaluate the overall patterns of care in different healthcare systems. If one system of care has, for instance, an 80% rate of appropriate use use of revascularization whereas another system has a 40% appropriate use of revascularization, then perhaps this discrepancy should be evaluated further.

Scenarios Where Revascularization was Deemed Either Appropriate or Inappropriate

STEMI

• Revascularization in STEMI patients greater than 12 hours from symptom onset who have no symptoms of ischemia or clinical instability was deemed inappropriate. Likewise the need for immediate angiography in these patients was deemed unnecessary.
• Revascularization of the non-culprit artery in STEMI patients who are not clinically unstable was deemed appropriate.

Stable Ischemia without Prior CABG

• High risk findings on non invasive testing, greater symptoms, a large burden of disease in the native vessels increases the likelihood that the revascularization is appropriate.
• In patients who have not undergone a stress test, PCI was deemed to be appropriate in the presence of 1 or 2 vessel disease with or without involvement of the proximal LAD if class III or IV anginal symptoms were present. The amount of medical therapy was not included in their consideration of appropriateness.
• In patients who have not undergone a stress test who have an intermediate stenoses, revascularization without further documentation of the significance of the stenosis by either FFR or IVUS was deemed inappropriate.
• In patients who have not undergone a stress test who have severe symptoms and either an abnormal FFR or IVUS, revascularization is appropriate.

Stable Ischemia with Prior CABG

• High risk findings on non invasive testing, greater symptoms, a large burden of disease in the native vessels or bypass conduits increases the likelihood that the revascularization is appropriate.

Limitations

The AUC does not take into account the severity or morphology of lesions but relies upon symptoms, the results of exercise stress testing, the use of medications and simply the location of the lesion(s).